Clinical Nursing Recommendations for the Treatment of the BTX-A Injections Due to Neurological Detrusor Overactivity ()
1. Introduction
Neurological detrusor overactivity (NDO) is characterized by spontaneous or provoked involuntary detrusor contractions during storage phase in urodynamic investigation which caused by various neurogenic diseases such as Parkinson’s disease, stroke and spinal cord injury [1] [2] . NDO can cause urinary incontinence, hydronephrosis, recurrent urinary tract infection, vesicoureteric reflux (VUR); the most dangerous being damage of renal function [3] . Botulinum toxin A (BTX-A) is a neuromuscular blocking agent indicated by the beneficial treatment effect on NDO patients who have an inadequate response to or are intolerant to anticholinergic medication [4] . Therefore, encouraged by our satisfactory clinical effects, we summarized our perioperative nursing experience for BTX-A injection.
2. Materials and Methods
A retrospective data analysis was performed. Patients who received BTX-A injections between August 2014 to July 2016, were analyzed. Characteristics in terms of gender, age, weight, time since SCI, neurological injury level, American Spinal Injury Association Impairment Scale were assessed. Inclusion criteria were: 1) at least 18 years old with urinary incontinence secondary to various neurogenic disorders; 2) urodynamics; 3) an inadequate response to oral anticholinergics or discontinued anticholinergics due to adverse events; 4) patients or their family caregiver skilled in clean intermittent catheterization (CIC). All patients provided written informed consent, and the local institutional review board at each center approved the protocol.
Injections were performed with no anesthesia or under epidural anesthesia in the operating room with a
21F
rigid cystoscope. The bladder was instilled with 100 - 150 ml sterile saline to achieve adequate visualization so as to avoid the blood vessels during injections. A 23 gauge needle (Cook Urological Incorporated) was inserted approximately
2 mm
into the detrusor. 200 U Botox® vials (100 U each) were reconstituted in a total of 30 ml sterile saline (6.7 U/ml). A total of 30 injections of 1 ml each were administered, evenly distributed about
1 cm
apart across the bladder wall [5] . A 16 Foley catheter had been inserted for 3 - 5 days. Comprehensive perioperative nursing was provided for patients with NDO prepared to accept detrusor botulinum toxin type A injection，by the means of in-depth observation，timely detection and reasonable solution to the clinical nursing issues．
Related adverse events were recorded. Statistical analysis was performed using the SPSS 13.0 soft-ware package (SPSS, Inc.,
Chicago
, IL). Statistical relationships between pre- and postoperative outcome parameters were sought by the Student’s t-test for quantitative variables. Statistical significance was considered at P value < 0.05.
3. Results
The records of 73 consecutive patients, who presented to the botulinum toxin consultation from August 2014 to July 2016, were analyzed. From these, 32 inpatients were treated with BTX-A for NDO.
The mean age was 27.4 years old (19 - 38 years). They were all on clean intermittent catheterization. Table 1 lists the baseline characteristics.
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Table 1. Baseline patients characteristics.
Abbreviations: SCI = spinal cord injury; AIS = American Spinal Injury Association Impairment Scale; CIC = clean intermittent catheterization. *Values are given as mean ± standard deviation; **Values are given as n (%).
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Table 2. Outcomes at baseline and week 12.
Pdetmax = maximum detrusor pressure during first involuntary detrusor contraction; VFIDC = volume at first involuntary detrusor contraction.
Table 2 shows that significant difference between outcomes at baseline and week 12 for Pdetmax (60.08 cmH2O vs. 28.04 cmH2O, P < 0.001), VFIDC (165.55 ml vs. 276.07, P < 0.001), and urinary incontinence respectively.
4. Discussion
The primary aim in the treatment of NDO is to ensure that the detrusor pressure remains within safe limits during both the filling phase and the voiding phase for protection of the upper urinary tract [6] . The present trial reports significant improvements in these parameters were evident with the 200-U dose of BTX-A injection [6] . Besides, the improvements in urodynamic outcomes also transfer to the increases in scores of the patient’s quality of life.
Undoubtedly, our prompt nursing care also played an important role in this significant clinical improvement. Timely psychological counseling and nursing significantly improve the patients’ negative psychology, enhanced their confidence with good postoperative recovery and symptoms improvement. During the preoperative period, we paid close attention to psychological condition and help patients reduce anxiety. Postoperative care included observation of related adverse events. Oral prophylactic antibiotics (except aminoglycosides) were administered on the day of treatment. The most important in nursing was to keep the catheter unobstructed and prevent and treat the infection. Patients received bladder irrigation with normal saline with the aim of preventing blockage resulted from continuing hematuria. After removal of catheter, patients kept on clean intermittent catheterization.
A limitation of this study is that the number of patients was relatively fewer. Therefore, further studies are warranted.
5. Conclusions
Our results have demonstrated that Patients were satisfied with the treatment and nursing by targeted perioperative nursing.
Acknowledgements
This study was supported by Medical Scientific Research Foundation of Guangdong Province, China (grant number B2017040, A2018124).